Year 1 OSCE Responding to Symptoms portfolio.
How to undergo an eye examination?
1. Wash hands
2. Look straight for the view of the pupil, cornea, and sclera.
3. Pull the lower lid and look up, left and right.
4. Gently lift the upper lid and look down, left and right.
5. To examine the conjunctiva, tell the patient to look directly into a near light and back at you – best
performed with a pen-torch to see the reaction of the pupils.
• Dry eye (keratoconjunctivitis sicca)
Who is the patient?
Dry eye syndrome is common as almost 3% of older adults develop dry eye each year and
its prevalence increases with age. It is more common in women than in men.
What is dry eye?
Dry eye is the frequent cause of eye irritation causing varying degrees of discomfort – it is chronic and has no
cure.
What can dry eye be caused by?
There are many causes for dry eye environmental (low humidity, wind, sun), occupational/lifestyle factors
(computer use, low blink rate, poor diet) and physical factors (age, hormonal changes
What are the specific symptoms caused by dry eye?
Affects both eyes and they have a burning, tired, itchy, irritated, and gritty sensation.
What medication can cause dry eye?
Diuretics, anticholinergic effective drugs, Isotretinoin, HRT, cardiac arhythmic drugs and SSRIs.
Why does dry eye occur?
The tear film has 3 important layers:
1. The innermost mucin layer allows the sticking of tears to the surface – which can be affected by
several goblet cells.
2. The middle aqueous layer contains 90% of the tear thickness.
3. The outermost lipid layer helps slow aqueous evaporation.
A reduction in any of these areas can affect the tear film and cause dryness alongside the underproduction of
tears being caused by increased evaporation, increased tear drainage and a decrease in tears at the lacrimal
gland.
What can be the differential diagnosis of dry eye?
KCS and Blepharitis are commonly mistaken for the symptoms of dry eye.
What are the specific questions to ask if dry eye has been suspected?
- Have you had daily, persistent irritation for the past 3 months?
- Do you have the recurrent sensation of sand or gravel in your eyes?
What OTC drugs can be given to treat dry eye?
Make sure to read the patient leaflet.
Drug Aetiology
Vizulize multi action eye wash and eye drop Hypromellose /Carmellose have film-forming and
emollient properties but doesn’t have ideal wetting
agents, so it needs hourly administration. They are
safe for pregnancy
Liquifilm Tears – preservative free option too Polyvinyl alcohol (1.4%) acts as a viscosity enhancer,
Refresh Ophthalmic it has the same surface tension as tears to make
, Sno Tears them good wetting agents so there is less dosing to
4 times a day.
Clinitas Gel Carbomer is used 1 drop 3-4 times a day, due to its
GelTears viscosity properties should be last instilled after
Liquivisc other eye drops. Avoid during pregnancy.
Viscotears
Lacri-Lube Wool fats contain a mixture of soft white paraffin,
liquid paraffin, and wool fat. They are useful at
bedtime as they can cause blurred vision. Can be
used during pregnancy.
Eyezin Xl Sodium Hyaluronate
Murine enhanced dry eye relief eye drops
What would you most likely prescribe to dry eye?
Sodium Hyaluronate is a good wetting agent and helps lubricate the eye – Thealoz Duo and Zaspray for itchy
and dry eye relief.
What questions to ask those with eye conditions?
- What eyes are affected?
- Do you have any discharge being released from the eyes?
- How would you describe the pain and discomfort?
- Are you experiencing redness in the eyes often?
- How long have you been experiencing this?
- Do your eyes water?
- Has your vision been affected – is it blurry?
• Blepharitis
Who is the patient?
Middle-aged people – especially those with dry eye
What is Blepharitis?
Can be classified into staphylococcal, seborrheic and meibomian glands dysfunction.
What is the anatomy of Blepharitis?
The Meibomian gland structure: The lipid or meibum is produced in cells that line the acini and is released into
the acinus, it collects in the central duct. Blinking creates pressure which forces the meibum into the excretory
duct and out onto the eyelid. They are found posterior to the eyelids, behind the eye at the top and bottom.
When blinking it has a significant impact on the delivery of meibum to the ocular surface, it spreads meibum
across the eye when lids collide, and the pressure of orbicularis against the globe stimulates meibum
production within the acini.
How is Blepharitis caused?
Blepharitis is a chronic condition and the rims of the eyelids become inflamed (red and swollen); it is caused by
the build-up of bacteria on the eyelids margin.
What are the two types of Blepharitis?
Anterior Blepharitis refers to staphylococcal and seborrheic causes as they affect the eyelashes.
Posterior Blepharitis refers to the meibomian gland dysfunction as these are on the posterior eyelid.
What is posterior blepharitis – meibomian gland dysfunction?
MGD is Meibomian Gland Dysfunction – it is a chronic condition. It included reduced oil production and it’s
caused by diet, ageing, and low blink rate. It is when the glands are blocked and clogged which eventually the
gland drops off and doesn’t regenerate. The glands on the top and bottom which allow tears to stick are
damaged then tears can evaporate which causes an irritable feeling.
, What are the symptoms of posterior blepharitis?
The symptoms are red eyes, gritty feeling, itchy eyes, and blurred vision.
What questions should be asked for Blepharitis – eyelid disorders?
How long have you had these symptoms – shows there is a chronic, persistent condition.
Are the eyelids showing any discomfort or redness - The lid margin can be inflamed and red.
Do they have any symptoms linked to conjunctivitis – as they can be linked?
What are the typical symptoms of Blepharitis?
The symptoms include crusty, irritated and redness on the eyelid margin, there is a build-up of debris which is
close to the root of the eyelash.
How do you treat Blepharitis?
As these are chronic conditions, they are not reversible, to manage this a management plan is advised. HCH
regime is recommended: heat, cleanse, and hydrate. This can involve a heated sleep mask on the eye for
periods of the team to stimulate oil glands, cleansing the eyes with wipes gently to allow movement of the
lipid oil layer and hydrating using eyedrops to keep eyes less irritable, there is the Hylo range which is typically
used to combat this.
How to undergo a physical ear examination?
1. Wash hands
2. Inspect the external ear for redness, swelling and discharge.
3. Apply pressure to the mastoid area which is behind the pinna – if tender then it shows otitis externa
or mastoiditis.
4. Move the pinna up and down to manipulate the tragus – if tender then it can indicate an external ear
involvement.
5. Examine EAM using a pen-torch to view the ear canal.
• Cerumen Impaction – ear wax impaction
How is ear wax formed?
Skin-lined external auditory canal of the outer ear contains sebaceous and apocrine
glands. These secrete a substance called cerumen into the canal. This secretion
combines with exfoliated cells of the stratum corneum and foreign particles to form
ear wax.
What is ear wax for?
It is for protecting the tympanic membrane by trapping foreign particles –
protection vs. infection.
How does ear wax self-clean the ear?
The ear wax expelled is because of the migration of epithelial cells to the ear canal
entrance. The process is facilitated by normal mouth movement.
What questions should we ask when dealing with excess ear wax?
- The course of symptoms?
- Associated symptoms – earache/ pain and ringing or dizzy?
- Activity and trauma to the ear?
When do we refer to the cases of excess cerumen?
- Pain in the middle ear
- Mucinous discharge – middle ear infection
- Trauma-related deafness/redness and swelling.
- Dizziness/tinnitus (inner ear)
- Elderly and children
